Choking as a cause of negative pressure pulmonary oedema (NPPE) in an older adult

Abstract

An 86-year-old female presented to the Emergency Department (ED) in respiratory distress after choking on a sandwich at home. Her family had noticed that she had had difficulty during and coughing after swallowing for several months. Her initial chest x-ray showed diffuse alveolar infiltrates in both lungs and blood tests showed normal white cells and C-Reactive Protein (CRP). She was started on intravenous antibiotics for presumed aspiration pneumonia and received 15 L of oxygen. However, the infiltration had dramatically improved, both radiologically and clinically, within 24 hours. She was diagnosed with negative pressure pulmonary oedema (NPPE) type 1 and made a rapid recovery. The Speech and Language Team diagnosed an impaired swallow and advised soft or bite-sized suitable foods. We discussed the ongoing risk of aspiration and long-term feeding options with the patient’s family. We agreed on a conservative plan for ‘risk feeding’, given her frailty and co-morbidities, and began discussions on ceilings of care. This case aims to raise awareness of NPPE so that it can be diagnosed, investigated and treated promptly. Although seen most commonly by intensivists and anaesthetists, it is relevant to those on the acute medical take and geriatricians managing patients with swallowing difficulties.

Negative Pressure Pulmonary Edema due to Upper Airway Obstruction in Two Dogs

“…PE is defined as fluid accumulation in the interstitial or alveolar space of the lung and is classified into two categories depending on the underlying causes: cardiogenic (CPE) and non-cardiogenic PE (NCPE) (Bouyssou et al, 2017;Glaus et al, 2010). NPPE is a well-known type of NCPE caused by upper airway obstruction such as chock, strangulation, tumors, or laryngospasms in humans (Bhattacharya et al, 2016;Lonergan et al, 2021;Herrick et al, 1990). Nevertheless, it could be a life-threatening emergency, and early diagnosis followed by rapid treatment of NPPE is still challenging because of the clinical similarities with other types of PE (Perina, 2003;Liu et al, 2019).…”

“…A previous study found that the survival-to-discharge rate for respiratory distress treated with PPV was 62.5% in 16 dogs, although the cause of respiratory distress was congestive heart failure (Edwards et al, 2014). Human patients who have upper airway obstruction attempt to inspire against the obstruction (Herrick et al, 1990;Lonergan et al, 2021). This effort generates very low intrathoracic pressure, which results in increased venous return from systemic circulation and preload that causes PE (Herrick et al, 1990;Bhattacharya et al, 2016).…”

Negative-Pressure Pulmonary Edema and Takotsubo Cardiomyopathy in the Older Adults

“…NPPE by choking does not occur without markedly negative intrathoracic pressure and is, therefore, more common in younger patients. However, there is a report of NPPE after upper airway obstruction caused by a sandwich in an older patient [ 5 ]. In our case, it was caused by shiitake mushrooms, a food item that is similar to a lid blocking the airway, and it is believed that this food item suddenly came in contact with the airway and blocked it completely, resulting in the development of NPPE.…”

Negative-pressure pulmonary Hemorrhaging Due to Severe Obstructive Sleep Apnea

“…NPPE is caused by excessive negative pleural pressure due to inspiratory effort during upper airway obstruction. The most common cause of NPPE is laryngeal spasm after extubation ( 2 , 3 ), epilepsy, and choking due to aspiration ( 4 , 12 , 13 ), but few cases of NPPE caused by sleep apnea have been reported.…”